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ความสัมพันธ์ของสมาชิกในบ้าน
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สภาพเศรษฐกิจของครอบครัว
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ความต้องการของผู้รับการคุ้มครอง
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การวินิจฉัยปัญหา
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การด าเนินการให้ความช่วยเหลือ
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ความเห็นของเจ้าหน้าที่ในการเยี่ยมครอบครัวผู้รับการคุ้มครอง
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ข้อเสนอแนะ
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ลงชื่อ...........................................................เจ้าหน้าที่ผู้เยี่ยมบ้าน
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ต าแหน่ง..............................................